The origins of the current heroin crisis in America can be traced back to the overprescription of opioid painkillers in recent decades. As opioid prescriptions and sales increased aggressively starting in the late 1990s, so too did rates of opioid addiction, overdose deaths, and users transitioning from prescription opioids to heroin. While heroin use has been an issue in the past as well, linked to wars and social movements, the current crisis is uniquely tied to changes in opioid prescribing practices that flooded the country with highly addictive pain pills and helped reintroduce heroin as a cheaper alternative to prescription opioids.

1. Origins of the Heroin Crisis
Presenters:
• Phillip Walls, RPh, Chief Clinical Officer, myMatrixx
• Andrew Kolodny, MD, Chief Medical Officer, Phoenix House
Foundation, Inc., and Executive Director, Physicians for
Responsible Opioid Prescribing
Moderator: Jackie L. Steele, Jr., JD, Commonwealth
Attorney, Kentucky 27th Judicial Circuit, and Vice
Chairman, Operation UNITE Board of Directors
Heroin Track

2. Disclosures
• Andrew Kolodny, MD, and Jackie L. Steele, Jr.,
JD, have disclosed no relevant, real or
apparent personal or professional financial
relationships with proprietary entities that
produce health care goods and services.
• Phil Walls, RPh - Employment and ownership
interest: Matrix HCS, Inc.

3. Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– John J. Dreyzehner, MD, MPH, FACOEM – Ownership
interest: Starfish Health (spouse)
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center

4. Learning Objectives
• Describe the history of heroin use in America, with
emphasis on its relationship to the Rx drug abuse
epidemic.
• Identify key roles for pharmacists and other health
professionals in identifying patients at-risk of heroin
abuse.
• Explain the relationship between the rising rates of
opioid addiction, heroin use and overdose deaths.
• Specify health interventions and policy responses to
the heroin crisis.
• Provide accurate and appropriate counsel as part of
the treatment team.

5. Heroin Track:
Origins of the Heroin Crisis

6. Why Focus on Heroin?

7. • $177 billion – annual cost of prescription drug abuse to
the US healthcare system
• The Drug Enforcement Administration (DEA) estimates
that diversion is a $25 billion-a-year industry
• $8.5 billion – annual cost of hospital admissions for people
who do not take their medications as prescribed
How did this happen?
Prescription Drug Abuse,
Misuse and Diversion

8. Timeline to Discovery of Heroin
• 1806 – morphine isolated from opium poppy – named after Morpheus,
the Greek god of dreams
– Heinrick Emanuel Merck – converted pharmacy into a full-time
producer of morphine – Engel-Apotheke or The Angel Pharmacy
– Today known as Merck and Company
• 1853 – invention of the hypodermic syringe and first
injection of morphine
– Co-invented by Alexander Wood and Charles Pravaz
– Woods’ wife was the first fatality of an injected overdose of
morphine
Alexander Wood
(1817 – 1884)

9. Timeline to Discovery of Heroin
• Dr. Woods’ discovery preceded the American Civil War by
almost a decade
– Approximately 400,000 soldiers became addicted to morphine
– Characterized as “old soldiers’ disease”
• One of these veteran’s was Colonel John Pemberton
– A pharmacist by training
– Mixed cocaine and the kola nut in an elixir to treat morphine
withdrawal
– Branded as Coca Cola in 1886
– Original formula with cocaine available until 1905
• 1874 - Diacetylmorphine is first synthesized

10. Timeline to Discovery of Heroin
Between 1878 and 1885 however opium addiction became much
more widespread among middle- to upper-class white women

11. Timeline to Discovery of Heroin
• Diacetylmorphine is “re-discovered” by
chemists working for Friedrich Bayer in the
mid-1880’s through a process known as
acetylation
– Morphine → diacetylmorphine
– Acetylsalicylic acid → aspirin
• Bayer named this drug heroin after the
German word heros meaning hero.
Morphine
Heroin
The two drugs differ
by the addition of
two acetyl groups

12. Metabolism of Opioids
*Not comprehensive pathways, but may explain the presence of apparently
unprescribed drugs
†6-MAM=6-monoacetylmorphine, an intermediate metabolite
Gourlay DL, et al. Urine Drug Testing in Clinical Practice: Dispelling the Myths & Designing Strategies [monograph]. 2004
hydrocodone
heroin6-MAM†
morphinecodeine
hydromorphone
oxycodone oxymorphone

13. Timeline to Discovery of Heroin
• Aspirin was first synthesized a year
later – ironically aspiring required a
prescription whereas heroin did
not
• Bayer and Merck had launched the
start of the modern day
pharmaceutical industry with the
development of three of the
world’s most popular analgesics:
morphine, heroin and aspirin

14. Trial Treatment – Free of Charge!

15. The Solution for Coughs

17. Early Attempts at Regulation
• 1906 – Pure Food and Drug Act – Coca Cola was
one of few products that survived this legislation
• 1914 – Harrison Narcotic Act
• 1919 – ruling by the Supreme Court that it was
unconstitutional to stop physicians from
prescribing narcotics for addicts, but then the
court later reversed that decision
• The case of Alexander Ameris – characterized as a
“dope fiend”

18. Prevailing attitude early to mid-
century
1900
• “…save our people from the clutches of this hydra-
headed monster which stalks the civilized world,
wrecking lives and happy homes, filling our jails and
lunatic asylums…”
Witherspoon JA. A protest against some of the evils in the profession of medicine. JAMA. 1900;34 :1589–
1592
1941
• “The use of narcotics in the terminal cancer patient is
to be condemned … due to undesirable side effects …
dominant in the list of these … is addiction”
Lee LE Jr. Medication in the control of pain in terminal cancer. JAMA 1941;116:216-219

19. The Vietnam War Era
• Represented a turbulent time in American history
• Janis Joplin dies of a heroin overdose on October 4, 1970
• The following May, Congressmen Steele and Murphy
conducted an official visit to Vietnam
• Their message upon returning: 15% of US servicemen in
Vietnam were addicted to heroin
• The timing coincided with the implementation of the
Comprehensive Drug Abuse Prevention and Control Act of
1970
• On June 17th of 1971, President Richard Nixon characterized
drug abuse as “a national emergency” - He asked Congress
to amend the Narcotic Addict Rehabilitation Act of 1966 to
increase access to methadone maintenance programs

20. America’s War on Drugs
• President Nixon’s legacy includes creation of the Drug
Enforcement Administration in 1973
• 1975: the Ford administration names marijuana a low-
priority drug
• 1976: Carter campaigns for de-criminalization of marijuana
• 1978: the Comprehensive Drug Abuse Prevention and
Control Act is amended to allow law enforcement to seize
“all things of value” involved in and exchange for controlled
substances
• 1981 – 1982: rise of the Medellin Cartel in Columbia and
creation of a bilateral extradition treaty between the
governments of Colombia and the United States

21. America’s War on Drugs
• 1984: Nancy Reagan launches her “Just Say No” campaign, which
becomes a focal point of President Reagan’s anti-drug campaign
• 1989: President Bush creates the Office of National Drug Control Policy
(ONDCP) and campaigns to “make drug abuse socially unacceptable”.
Spending for treatment and law enforcement increase under the
ONDCP, but the budget for treatment is less than one-third that of law
enforcement.
• 1993: President Clinton signs the North American Free Trade
Agreement (NAFTA). This agreement results in a significant increase in
legitimate trade shipments across the Mexican-US border, but has the
unintended consequence of making it difficult for US Customs agents
to find contraband narcotics in these shipments.
• 2000: President Clinton commits $1.3 billion in aid to Colombia to fight
drug trafficking.

22. America’s War on Drugs
It is important to note in
the War on Drugs that the
DEA announced just this
past May the most
successful enforcement
action in its history:
known as Operation
Pilluted, this operation
resulted in 280 arrests
including 22 doctors and
pharmacists; resulted in
the seizure of $11,651,565
US currency and
$6,745,800 in real
property.

23. The Prescription Opioid & Heroin Crisis:
Responding to an Epidemic of Addiction
Andrew Kolodny, M.D.
Chief Medical Officer, Phoenix House Foundation Inc.
Executive Director, Physicians for Responsible Opioid Prescribing
Senior Scientist, Heller School for Social Policy and Management, Brandeis University

24. Opium

25. Primary non-heroin opiates/synthetics admission rates, by State
(per 100,000 population aged 12 and over)

26. Primary non-heroin opiates/synthetics admission rates, by State
(per 100,000 population aged 12 and over)

27. Primary non-heroin opiates/synthetics admission rates, by State
(per 100,000 population aged 12 and over)

28. Primary non-heroin opiates/synthetics admission rates, by State
(per 100,000 population aged 12 and over)

29. Primary non-heroin opiates/synthetics admission rates, by State
(per 100,000 population aged 12 and over)

30. Primary non-heroin opiates/synthetics admission rates, by State
(per 100,000 population aged 12 and over)

31. Non-heroin opioid treatment admissions: 2013
SOURCE: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services
Administration, Treatment Episode Data Set (TEDS). Data received through 01.23.15.

32. Unintentional overdose deaths involving opioid analgesics
parallel per capita sales of opioid analgesics in morphine
equivalents by year, U.S., 1997-2007
0
100
200
300
400
500
600
700
800
0
2000
4000
6000
8000
10000
12000
14000
'97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07
Source: National Vital Statistics System, multiple cause of death dataset, and DEA ARCOS
* 2007 opioid sales figure is preliminary.
Number of
Deaths
Opioid sales
(mg/person)
*

33. 0
1
2
3
4
5
6
7
8
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Rate
Year
Opioid Sales KG/10,000 Opioid Deaths/100,000 Opioid Treatment Admissions/10,000
Rates of Opioid Sales, OD Deaths, and Treatment, 1999–2010
CDC. MMWR 2011

36. Source: United States General Accounting Office: Dec. 2003, “OxyContin Abuse and Diversion and
Efforts to Address the Problem.”
Dollars Spent Marketing OxyContin (1996-2001)

37. Industry-funded “educational” messages
• Physicians are needlessly allowing patients to suffer
because of “opiophobia.”
• Opioid addiction is rare in pain patients.
• Opioids can be easily discontinued.
• Opioids are safe and effective for chronic pain.

38. Industry-funded organizations campaigned for
greater use of opioids
• Pain Patient Groups
• Professional Societies
• The Joint Commission
• The Federation of State Medical Boards

39. Porter J, Jick H. Addiction rare in patients treated with
narcotics. N Engl J Med. 1980 Jan 10;302(2):123
Cited 824 times (Google Scholar)
“The risk of addiction is much less than 1%”

40. N Engl J Med. 1980 Jan 10;302(2):123.

41. 0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
20,000
22,000
24,000
26,000
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Painkillers Heroin Total Opioid
Year
Opioid Related Overdose Deaths: 1999-2013

42. Heroin treatment admissions : 2003-2013
SOURCE: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services
Administration, Treatment Episode Data Set (TEDS). Data received through 01.23.15.

43. Death rates from overdoses of heroin or prescription opioid
pain relievers (OPRs), by age group
SOURCE: CDC. Increases in Heroin Overdose Deaths — 28 States, 2010 to 2012
MMWR. 2014, 63:849-854

44. Heroin admissions, by gender, age, and race/ethnicity:
2013
SOURCE: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health
Services Administration, Treatment Episode Data Set (TEDS). Data received through 01.23.15.

45. Deaths involving heroin, by age and race/ethnicity
2000 and 2013

46. Controlling the epidemic:
A Three-pronged Approach
• Prevent new cases of opioid addiction.
• Treatment for people who are already addicted
• Reduce supply from pill mills and the black-
market.

47. How the opioid lobby frames the problem:
Source: Slide presented by Lynn R. Webster MD at FDA meeting on
hydrocodone upscheduling, January 25th, 2013.

48. Pain Patients “Drug Abusers”
35% met DSM V criteria for an opioid
use disorder1
1. Boscarino JA, Rukstalis MR, Hoffman SN, et al. Prevalence of prescription opioid-use disorder among chronic pain patients:
comparison of the DSM-5 vs. DSM-4 diagnostic criteria. J Addict Dis. 2011;30:185-194.
This is a false dichotomy
Opioid harms are not limited to so-called “drug abusers”
92% of opioid OD decedents
were prescribed opioids for
chronic pain.2
2. Johnson EM, Lanier WA, Merrill RM, et al. Unintentional Prescription Opioid-Related Overdose Deaths: Description of
Decedents by Next of Kin or Best Contact, Utah, 2008-2009. J Gen Intern Med. 2012 Oct 16.

50. Heroin treatment admissions with planned
medication-assisted opioid therapy 2003-2013
SOURCE: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services
Administration, Treatment Episode Data Set (TEDS). Data received through 01.23.15.

51. Summary
• The U.S. is in the midst of a severe epidemic of
opioid addiction
• To bring the epidemic to an end:
– We must prevent new cases of opioid addiction
– We must ensure access to treatment for people
already addicted

52. Origins of the Heroin Crisis
Presenters:
• Andrew Kolodny, MD, Chief Medical Officer, Phoenix House
Foundation, Inc., and Executive Director, Physicians for
Responsible Opioid Prescribing
• Phillip Walls, RPh, Chief Clinical Officer, myMatrixx
Moderator: Jackie L. Steele, Jr., JD, Commonwealth
Attorney, Kentucky 27th Judicial Circuit, and Vice Chairman,
Operation UNITE Board of Directors
Heroin Track